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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609061
Report Date: 12/18/2021
Date Signed: 12/18/2021 03:09:52 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210204135140
FACILITY NAME:WEST VALLEY ASSISTED LIVINGFACILITY NUMBER:
197609061
ADMINISTRATOR:MILLAN, JONATHANFACILITY TYPE:
740
ADDRESS:7055 SHOUP AVENUETELEPHONE:
(818) 883-7201
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:0CENSUS: 41DATE:
12/18/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Vilma ColochoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Questionable Death.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. This investigation was conducted by Olivia Spindola, Investigator with Community Care Licensing Division’s Investigations Branch.

During the investigation Investigator Spindola conducted interviews with Resident 1 (R1)’s family members, facility residents, facility staff and R1’s physician. Investigation revealed that on 1/5/2021 at 02:45 am R1 was found by facility staff lying on the ground beneath R1’s 2nd story window. Prior to ambulance transport R1 was breathing and communicating R1 was admitted to the hospital. Prior to the incident R1 stopped taking one prescribed medication. Facility staff were unable to convince R1 to take the medication as per physician’s instructions for approximately 10 days. According to R1’s physician the missed medication would not cause R1 to become suicidal. On 1/4/2021 R1 was prescribed medication for the treatment of sleeplessness and hallucinations. Staff attempted to have R1 hospitalized but were told by medical personnel that there was no space due to COVID-19 and R1 was “not sufficiently incapacitated to require hospitalization”
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20210204135140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WEST VALLEY ASSISTED LIVING
FACILITY NUMBER: 197609061
VISIT DATE: 12/18/2021
NARRATIVE
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 During the course of the investigation Investigator Spindola determined that there was insufficient evidence to corroborate the allegation that the death of R1 was due to negligence on the part of facility staff. The Allegation is Unsubstantiated.

Approximately 2:45 pm LPA spoke with the administrator Jonathan Millan via telephone. Mr. Millan was unable to come to the facility and designated staff Vilma Colocho to sign for the report.

Exit interview conducted copy of report and appeal rights emailed to JON@WESTHILLSALF.COM
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210204135140

FACILITY NAME:WEST VALLEY ASSISTED LIVINGFACILITY NUMBER:
197609061
ADMINISTRATOR:MILLAN, JONATHANFACILITY TYPE:
740
ADDRESS:7055 SHOUP AVENUETELEPHONE:
(818) 883-7201
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:0CENSUS: 41DATE:
12/18/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Vilma ColochoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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facility staff failed to address R1’s needs.
INVESTIGATION FINDINGS:
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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan.

Regarding the above Allegation LPA Avetisyan conducted reviews of records, interviewed the licensee representative, Resident 1 (R1)’s Primary Care Physician (PCP). Information obtained during the investigation revealed the following: Prior to the fall incident various staff observed that R1 appeared confused, was unable to sleep and was Hallucinating. Approximately 10 days prior to the fall incident R1 was refusing to take the prescribed medication Loxapine. According to staff several attempts were made to reach R1’s psychiatrist. Review of staff documentation revealed that R1’s physician was contacted only once at which time a message was left. Facility Centrally Stored Medication and Destruction log and medication administration log also documented that R1’s prescription for Loxapine ran out on 12/19/2020. The pharmacy was called, and the medication was refilled on 12/23/2020. R1 started to take the Loxapine on 12/28/2020. When the LPA requested additional documents from the assistant administrator LPA received the same Medication Administration Record (MAR) which documented that resident refused medication on 12/19/2020 and facility that staff left a message for the psychiatrist on 12/21/2020.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20210204135140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WEST VALLEY ASSISTED LIVING
FACILITY NUMBER: 197609061
VISIT DATE: 12/18/2021
NARRATIVE
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 Other information obtained revealed that the day before the fall (1/4/20), facility doctor ordered Halidol to be given to R1 for sleep and hallucinations, however facility records do not document that medication was ordered, received, or administered to R1. When interviewed on 4/14/2021 Licensee Ginger PO (CEO) stated that several days before the fall resident was confused. The staff called Culver City Hospital where the facility physician has privilege, however R1 was refused hospitalization. On an unknown date staff called 911 due to the confusion however R1’s sister refused transport. It was reported that R1’s sister has power of attorney for resident however the licensee failed to obtain documentation to confirm. R1’s facility records and physicians report documented that R1’s PCP is Dr. Aazmi who was not contacted when R1 refused medications. Based on the information obtained the department has determined that Facility personnel did not attempt to contact R1’s PCP, nor did they make additional attempts to reach the psychiatrist when the decline in condition was observed. Facility personnel did not obtain and/or assist R1 with medication as directed by the facility physician and did not obtain timely medical care. The licensee, administrator and facility staff failed to address R1’s needs therefore the allegation is Substantiated.

Approximately 2:45 pm LPA spoke with the administrator Jonathan Millan via telephone. Mr. Millan was unable to come to the facility and designated staff Vilma Colocho to sign for the report.

Exit interview conducted copy of report, citations and appeal rights emailed to JON@WESTHILLSALF.COM
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210204135140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WEST VALLEY ASSISTED LIVING
FACILITY NUMBER: 197609061
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2021
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee/Administrator will develop a comprehensive plan/procedure to ensure that residents medications are refilled prior to running out to ensure that medications are given according to the physicians directions at all time and what steps will be taken when residents refuse medications. Copy of the plan/procedure will need to be submitted as POC.
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Based on interview and record review, the licensee/administrator did not comply with the section cited by not ensure R1's medication was given according to the physicians direction which posed an immediate health and safety and personal rights risk to R1.
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Type A
12/20/2021
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as deterioration of mental ability are observed, the licensee shall ensure that such changes are documented & brought to the
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Licensee/Administrator will develop a written plan/procedure indicating what steps will be taken to ensure staff ensure that residents primary care physicians are notified of any changes in the residents condition. Copy of the plan/procedure will need to be submitted as POC.
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attention of the resident's physician.. This requirement was not met as evidenced by: Information obtained during the investigation which revealed that the licensee did not comply with the section cited by failing to notify R1's PCP of R1's change in condition and refusal of medication which posed an immediate health, safety personal rights risk to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5